Crohn's Disease-associated Fistulas Research Articles

Sa1851 The Role for T Cells in the Pathogenesis of Crohn's Disease-Associated Fistulae

Sa1851 The Role for T Cells in the Pathogenesis of Crohn's Disease-Associated Fistulae

Gluteal fold flap in perineal reconstruction for Crohn's disease-associated fistulae

Crohn's disease is increasing in incidence worldwide. It is associated with many complications including fistulae, which may require surgical intervention. Occasionally, formal perineal reconstruction is needed for extensive or definitive fistula surgery. Reconstruction for inflammatory disease presents unique challenges and often calls for innovative solutions. Gluteal fold flaps (GFFs), which have been widely used in vulvo-vaginal malignancy and anorectal cancer surgery, have not hitherto been reported for Crohn's disease-associated fistulae. A 30-year-old female presented with a 5-year history of Crohn's-associated perianal and rectovaginal fistulae. She had a previous small bowel resection and ileostomy. A laparascopic pan-proctocolectomy was carried out followed by perineal reconstruction in a single stage procedure using a pedicled fasciocutaneous GFF. Seven months postoperatively, revisional surgery was carried out using the contralateral GFF due to two areas of persistent wound dehiscence. The outcome was complete resolution of the fistulae, stable wound closure and good cosmesis. This case demonstrates that it is practical to use the GFF for perineal reconstruction following excision of complex Crohn's-associated fistulae. The flap avoids the sequelae associated with sacrifice of regional muscle flaps and specifically circumvents the unavailability of the rectus abdominis flap in slim patients or those with in-situ ileostomies. It is easy and quick to raise and does not require an intra-operative change in the patient's position. The GFF ensured well vascularised skin cover, adequate flap volume with no loss of function and low donor site morbidity.

Su1261 Expression of Interleukins 22 and 33, Matrix Metalloproteinases 9 and 13, Mast Cell Markers and Hypoxia-Inducible Factor 1α in Crohn's Disease Associated Fistulae

Background and aim : Colitis-associated colorectal cancer (CAC) affects individuals with inflammatory bowel disease (IBD) more often and younger than cancer in the general population. Colonoscopy provides the surveillance gold standard. Changes to surveillance intervals have been made given data demonstrating that endoscopic appearance is an important predictor of future dysplasia or cancer, but adjuvant, non-invasive clinical tools are still warranted to improve surveillance outcomes and to assist in management and interpretation of dysplasia. Methylation markers may be able to do this. Material and methods : Methods: using reexpression profiles of colon cancer cell lines, candidate genes were identified; promising markers were tested on tissue using the Base5 methylation-profiling platform. Promoter sequences were linked with gene expression to identify epigenetically silenced genes.Marker candidates were screened using methylation specific PCR assays to assess the methylation status of 2 gene promoters (FOXE1, SYNE1) in biopsies from 93 longstanding IBD patients and 30 healthy controls. Samples included colitis-associated colorectal adenocarcinomas (n= 25); IBD-associated dysplastic lesions (n=29); adenomas arising on a background of UC (n= 8); samples from IBD patients with no neoplasia (n=31) and healthy controls (n=30). Results : The presence of the 2 genes significantly varied between the groups. Both were increasing likely with increased disease severity. Neither occurred in controls, whilst 60% of CAC patients had FOXE1, and 80% of CAC patients had SYNE1. Conclusions : FOXE1SYNE1 methylation markers panel demonstrated significantly increased expression in neoplastic tissue. Syne1 was highly represented in CAC. Methylation of these promoter genes might be considered a potentially useful pathology marker of neoplasia in longstanding inflammatory bowel disease.

Mo2039 Dickkopf-Homolog-1 Regulates Tumor Growth Factor-Beta Induced Interleukin-13 Expression: Implications for the Pathogenesis of Crohn's Disease Associated Fistulae

Mo2039 Dickkopf-Homolog-1 Regulates Tumor Growth Factor-Beta Induced Interleukin-13 Expression: Implications for the Pathogenesis of Crohn's Disease Associated Fistulae

OP20 TNF and MDP induce epithelial-to-mesenchymal transition in human intestinal cells: Implications for the pathogenesis of Crohn's disease-associated fistulae and the use of anti-TNF antibodies

OP20 TNF and MDP induce epithelial-to-mesenchymal transition in human intestinal cells: Implications for the pathogenesis of Crohn's disease-associated fistulae and the use of anti-TNF antibodies

A Role for Snail Family Transcription Factors in the Aetiology of Crohn's Disease-Associated Fistulae

A Role for Snail Family Transcription Factors in the Aetiology of Crohn's Disease-Associated Fistulae

Anal Fistula Plug

This study was designed to analyze the efficacy of the Cook Surgisis AFP anal fistula plug for the management of complex anal fistulas. This was a retrospective review of all patients prospectively entered into a database at our institution who underwent treatment for complex anal fistulas using Cook Surgisis AFP anal fistula plug between July 2005 and July 2006. Patient's demographics, fistula etiology, and success rates were recorded. The plug was placed in accordance with the inventor's guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. Thirty-five patients underwent 39 plug insertions (22 men; mean age, 46 (range, 15-79) years). Three patients were lost to follow-up, therefore, 36 procedures to be analyzed. The fistula etiology was cryptoglandular in 31 (88.6 percent) patients and Crohn's disease associated in the other 4 (11.4 percent). There were 11 smokers and 3 patients with diabetes. The mean follow-up was 126 days (standard = 69.4). The overall success rate was 5 of 36 (13.9 percent). One of the four Crohn's disease-associated fistulas healed (25 percent) and 4 of 32 (12.5 percent) procedures resulted in healing of cryptoglandular fistulas. In 17 patients, further procedures were necessary as a result of failure of treatment with the plug. The reasons for failure were infection requiring drainage and seton placement in 8 patients (25.8 percent), plug dislodgement in 3 (9.7 percent), persistent drainage/tract and need for other procedures in 20 patients (64.5 percent). The success rate for Surgisis AFP anal fistula plug for the treatment of complex anal fistulas was (13.9 percent), which is much lower than previously described. Further analysis is needed to explain significant differences in outcomes.

Diagnosis and management of fistulizing Crohn's disease

The transmural inflammation characteristic of Crohn's disease predisposes patients to the formation of fistulas. Up to 50% of patients with Crohn's disease are affected by fistulas, which is a major problem given the considerable morbidity associated with this complication. Appropriate treatment of fistulas requires knowledge of specific pharmacological and surgical therapies. Treatment options depend on the severity of symptoms, fistula location, the number and complexity of fistula tracts, and the presence of rectal complications. Internal fistulas, such as ileoileal or ileocecal fistulas, are mostly asymptomatic and do not require intervention. By contrast, perianal fistulas can be painful and abscesses may develop that require surgical drainage with or without seton placement, transient ileostomy, or in severe cases, proctectomy. This Review describes the epidemiology and pathology of fistulizing Crohn's disease. Particular focus is given to external and perianal fistulas, for which treatment options are well established. Available therapeutic options, including novel therapies, are discussed. Wherever possible, practical and evidence-based treatment regimens for Crohn's disease-associated fistulas are provided.

Gracilis Muscle Interposition for the Treatment of Rectourethral, Rectovaginal, and Pouch-vaginal Fistulas

The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Drug therapy for inflammatory bowel disease: Part II

Part II of this two-part article (See The American Journal of Surgery 1992; 164: 85-9) reviews the current definition of the role of immunosuppressive therapy in inflammatory bowel disease (IBD) and the use of antibiotics in IBD, as well as summarizes the uses of the new agents on the horizon for the treatment of IBD. Azathioprine and 6-mercaptopurine have steroid-sparing effects in patients with refractory Crohn's disease and ulcerative colitis, treat Crohn's disease-associated fistulas, and are the first agents to demonstrate efficacy in the prophylaxis of Crohn's disease. Their low risk for the development of lymphoreticular malignancy remains a factor in decisions regarding their long-term use. Cyclosporine is steroid sparing in active chronic Crohn's disease and, given intravenously, may help treat severe, refractory ulcerative colitis. Antibiotics have expanding roles: metronidazole is effective for the primary treatment of Crohn's disease, fistulas, abscess, bacterial overgrowth, and pouchitis (after ileoanal anastomosis). Other potential agents show promise in pilot studies but await controlled trials.